By Adam V. Russo, Esq.
(As published in Thompson Information Services’ Employer’s Guide to Self-Insuring Health Benefits)
If you are a long time reader of mine, I would first like to say thank you for being the only person other than my mother to read what I write. It is extremely kind of you to do so! As a loyal reader, you would also know that it doesn’t take a lot to get me going and in the self insured industry it seems like something new happens on a weekly basis that gets my water boiling. For the past few years, amongst the threat of the exchanges and the state regulation of stop loss, nothing has bothered me as much as the wraps! Wrap networks that is. If PPO networks weren’t bad enough, in case you have a claim that doesn’t belong to a network, you can always pay the claim through the wrap network. So if one network wasn’t enough, with a wrap you can even work with more.
What we have is an industry phenomenon. TPAs and self funded plans complain about their networks all the time. How the discounts are bad, how you don’t have the ability to audit the claims, how the networks really work on behalf of the hospitals and not the plans. Everyone seemed to complain about them yet need them to attract clients that aren’t willing to go the reference based pricing route. You need a network to survive as I am told by every executive that has been in the industry longer than I have been alive.
Yet at the same time, these professionals long for the day when they see a large claim and have the ability to fight the facility about the excess charges, save their clients money, look like a hero to the broker, have the stop loss carrier thank them, and make the TPA some extra revenue from the savings they found. The problem is they have this option right now and it’s called the out of network or wrap network claim. Every day I see TPAs and self funded employee benefit plan throw good money down the proverbial toilet.
Wraps are everywhere yet I don’t see how they can actually help any self insured plan. Before I start ranting about wrap networks too much, let me formulate a typical example for you and I will use our own self funded plan to illustrate. The Phia Group’s self funded plan has primary access to the Blue Cross network in Massachusetts. Over 98% of all of my plan’s claims are under $1000 and there is a network discount that applies to all in network facilities. I cannot audit these claims, I cannot negotiate these claims but the reality is that I do not need to and I don’t want to. The claims are small and the discounts off the charges are reasonable. There is no need to make much of a fuss. Now, the remaining 2% of claims are the issue and while my hands are pretty much tied on the large in network claims, luckily I am in Boston where there is a lot of competition for my dollar and the charges by the well respected hospitals in the city aren’t too much when compared to Medicare pricing. So, you must be asking by now where is the problem.
The problem exists when there is a large claim outside of my network. For example, let’s say I am on business in Montana and while on a trip, I decide to go skiing. Let’s knock on some wood please as I keep the hypothetical going. Let’s say I break my leg and need to be rushed to a rural hospital that is obviously not in my network. This would be viewed as an out of network claim. At this point I have two options, hire a negotiator to get the claim resolved or access a wrap network through my administrator that can offer immediate access to discounts without having to worry about picking up the phone and trying to work out a deal and ensure that there is no balance billing to me. Even when the plan or administrator hires a firm to negotiate a claim, all that may be happening is that the negotiating firm is accessing the wrap discount rate and making a quick deal. They aren’t negotiating anything but you think they are. They are just accessing the same wrap network rate that anyone else (including you) can. It’s stealing your money since not only are you paying way too much on the claim, you are paying the negotiation company a percentage of the so called savings for doing two minutes of work for you.
Wrap networks are a great option on a low dollar claim when the hassle of negotiating a deal isn’t worth the money but most out of network claims are large claims since they are typically emergency situations. The greatest thing about wrap networks is that you do not have to use them! This is what most of my clients do not understand. There is a huge difference between a primary network and a wrap network. The biggest being that contractually you may be bound to pay the network rate on a primary PPO regardless of how outrageous the claims may be but in the wrap scenario, the use of the wrap is optional. This is absolutely huge when it comes to finding some true savings.
I have spent almost two years convincing my TPA clients that there is a distinct difference between primary network and wrap claims yet so many administrators use the same claims process on both. In this industry when someone says in-network they include wrap claims top that definition but they are just dead wrong. Educating plan administrators on this is huge since if people do not know they have options then they will never choose an option. As you know, the plan has a fiduciary duty to be prudent with plan assets. Too many times they are being fooled by these so called cost containment firms that these claims are being negotiated when all that is happening is that the company is applying the agreed up wrap discount rate. It’s embarrassing that we have snake oil salesmen in our industry but the reality is that we have plenty of them.
If you want to save some easy money for your plan, carve out these large out of network claims, place strong language into your plan document, and hire a true claims negotiation firm that will use innovative data and legal techniques to negotiate a fair deal and get signed off agreements on each claim. A single claim can save your plan hundreds of thousands of dollars. I see millions upon millions wasted every month by those in the dark. Please do not continue to be one of them.
There is widespread confusion in the marketplace as the claim negotiation companies like to state that they negotiate your claims but the reality is that in many instances there is no actual negotiation as these vendors just access the wrap network so-called discounts and spend approximately 5 seconds on the actual claim. Basically anyone on the street could actually get the same discounts that many of these wraps have just by picking up the phone and calling the facility. You just tell them that you want 20% off the bill in exchange for sending the money within 30 days. People do this with their credit card bills every day. There is an entire industry built around credit card negotiations. This is no different as you can do this yourself. Think about it – these are out of network claims that otherwise would have balance billing to the member. Do you really think that these facilities want to be chasing dollars from members by collecting ten dollars a week? Of course not! They want the money from the deep pockets of a health plan right away even if it’s 50 cents on the dollar.
Then there is the actual wrap contract that is no better in most cases than the typical primary network access contract. The rate is set at the percentage of billed charges and with wraps the discounts are much smaller that the primary networks. In addition, the plan is also specifically prohibited from using any sort of usual and customary or clinical editing logic. Therefore, the one time you can actually audit the claim for excess charging, you agree not to! The wrap agreement is also tethered to a participating provider agreement – and that, of course, is still confidential like in primary networks.
The bottom line is that wrap contracts are just as bad as primary contracts, except often worse, because the discounts are lower. A TPA is doing its groups a disservice if it accesses a wrap network instead of negotiating claims. That’s especially true when it comes to a complimentary or supplemental wrap when the payer is not obligated to use the wrap. In these situations it would be insane not to negotiate the claims. A claim that can be out of network if the payer so chooses is always better off paid as out of network with the ability to negotiate than using a wrap network meager discount.
The best approach is to have well written plan document language that gives you the best possible weaponry to negotiate these claims. You must leverage favorable plan language into settlements with providers that result in a plan payment of far less than it would have otherwise had to pay if a network rate was used.
There are hundreds of vendors that negotiate claims; most TPAs are either familiar with more than a few or perform their own negotiations. Either way, though some providers will negotiate robotically without regard to whether the plan is required to pay their bills, others – including the most egregiously charging ones, with expensive legal counsel to prevent exactly this – scrutinize the plan document language and are able to pick apart arguments to negotiate. Defining usual and customary as the prevailing charge in the area, grouping payment based on the provider rather than the claim, and not affording the plan administrator the proper discretion to determine payable amounts are examples of plan language that will make cost containment unduly difficult.
Here is what you should be stating in your plan document to ensure the most rights possible when it comes to negotiating large out of network claims. The plan should state that claims must be reasonable meaning that services and fees are in compliance with generally accepted billing practices for unbundling or multiple procedures. Usual and customary shall mean the lesser of fees that a provider most frequently accepts from the majority of patients for the service or supply, the cost to the provider for providing the services, the prevailing range of fees accepted in the same area by providers, and the Medicare reimbursement rates. Usual and Customary charges may be determined and established by the Plan using normative data such as Medicare cost to charge ratios, average wholesale price for prescriptions and manufacturer’s retail pricing for supplies and devices.
At the end of the day, you want to give your plan as many options as possible to get the biggest savings possible on a claim. Networks – especially large ones – are not known for their sensitivity to the plan’s problems. There are dozens of different scenarios that can arise within any given plan that will lead to a dispute with the network over payable amounts. Having clear language that comports with network agreements and discussions with providers regarding carve outs are crucial aspects of effective cost containment programs when using networks. Some networks allow plans to engage in creative cost containment techniques such as carving out dialysis, specialty drugs, air ambulance claims, and carving out certain specific providers – but many others don’t.
Here is my bottom line – if you have a large claim (define large based on your risk level) and have the ability to negotiate the claim, do it. Prepare yourself for the opportunity by having the best possible language in your plan document, ensuring that your administrator doesn’t automatically send these claims to a wrap network that you don’t need to use, and ensure that you work with a claims negotiator that not only has the ability to work a claim but has access to the best claims data, legal minds, and plan language to ensure maximum savings. Besides it’s your fiduciary duty to do it so stop breaching your obligation to be prudent with plan assets. The employee benefit plan bank account will thank you for it.